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m (NowWaste Tire Survey & Inspection Report Inspection Report NumberStato of Callfornia Survey Form - Page 1 7 - 4 7CIWMBIa1ad04) <br /> California Integrated Wavle Manaagement Board <br /> 15 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 13uslness Profile Inspection Details <br /> TPIp- Inspection_ Inspection Type (Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP O CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _Vra.a, <br /> Physical Addrs <br /> _ 1 �5 �7� Inspection Date <br /> (\—?/`11 Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> , I <br /> QPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f I.Active • Passenger 0 Generator 0 Outdoor <br /> O O Closed t�Altered <br /> GPS Latitude 10 Hauler (J Indoor <br /> 0 0 Inactive Truck <br /> Longitude — 0 Planned 0 OTR O End-Use I. Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> V A HAULING AND MA FEST REQUIREMENTS :' r <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires D.N9tia41,S7f �(Ipfanjf{fitljltj <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. OltM <br /> O O § 9 ; <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> t <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Dite <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days �� y �,� , 1 „ r i <br /> v <br /> -i .� .k ems. T` /i �✓/c�6,✓.��1. <br /> 0 0 s 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 0 <br /> Other: § <br /> Comments <br /> p�`�J¢.rf- <br /> Inspection Form Included: 0 Cir} <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number ns s Slgnatur Phone Number <br /> i — <br /> INSTRUCTIONS ON BACK 12 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LFA © ■ <br />